Those Devilish Cramps

As common as cramps are, no one knows exactly what causes them. Here’s a look at the latest theories, and the latest cures.

By Richard “Biff” Williams

Richard “Biff” Williams, PhD, ATC/L, is the Athletic Training Program Director and an Assistant Professor in the School of Health, Physical Education, and Leisure Services at the University of Northern Iowa.

Probably since the time a caveman first set off after a saber-toothed tiger, and certainly through the history of organized sport, one ailment has plagued physically active people above all others: muscle cramps. Even today, athletic trainers spend a considerable amount of their time treating and trying to prevent muscle cramps. Yet, little remains known about what causes cramps, and, therefore, how to prevent them.

Recently, the National Athletic Trainers’ Association addressed the issue in position statements on heat illness and fluid replacement for athletes. While these statements provide information useful in preventing muscle cramps, many athletes will continue to be afflicted by cramps despite these preventive measures.

Perhaps that’s why there was such a flurry of interest following media reports of professional athletes using pickle juice or mustard to prevent and treat exercise-associated muscle cramps. While these homemade remedies show promise, there is now a danger of amateur athletes thinking that they simply have to trade in their water bottles for jars of pickles.

In this article, I will take a look at what muscle cramps are, several theories that attempt to explain how they are caused, and discuss prevention and treatment options. I will also explain the role that pickle juice and mustard may play in preventing and treating exercise-associated muscle cramps.

A Pain in the ___Muscle cramping is a painful, spasmodic, involuntary muscle contraction that regularly frustrates athletes and their athletic trainers. Muscle cramps are defined by their cause, which can be classified into three main categories: congenital abnormalities, acquired medical diseases, and specific acquired skeletal muscle cramp syndromes. When an athlete has a problem with muscle cramping, each of these classifications must be considered to properly treat the problem.

A congenital abnormality is a condition that has been passed on through genetics. Common congenital abnormalities that cause muscle cramping are metabolic disorders (such as glycogen storage diseases, carnitine palmityl transferase deficiency, myoadenylate deaminase deficiency, or other syndromes, such as an autosomal-dominant cramping disease).

Once a congenital abnormality has been eliminated as the possible cause of muscle cramping, acquired medical diseases need to be investigated. These can be divided into six categories: 1) neuromuscular diseases, such as nerve root compression, peripheral neuropathy, and myotonic dystrophy; 2) endocrine diseases, like diabetes mellitus or thyroid disease; 3) fluid and electrolyte abnormalities, such as hyponatremia, hypokalemia, and hyperkalemia; 4) pharmaceutical agents, including nifedipine, ethanol, penicillamine, and diuretics; 5) toxins, such as lead toxicity, tetanus, or a black widow spider bite; and 6) other medical conditions, including diarrhea, sarcoidosis, and cirrhosis of the liver.

Far more common, though, are the acquired skeletal muscle cramp syndromes. These are: 1) exercise-associated muscle cramps (EAMC), which are the most common among athletes; 2) occupational cramps, such as writer’s cramp; 3) nocturnal calf muscle cramps—cramps that occur at night, mostly to the elderly—and 4) pregnancy-associated cramps.

Although it’s important to keep all four types in mind when dealing with cramping, EAMC are the most commonly seen by athletic trainers. Although there are no specific epidemiological studies identifying how many athletes suffer from muscle cramping, it is well known that muscle cramping can severely affect performance in athletes.

There are several risk factors for EAMC, including older age, a long history of running, a higher body mass index, poor stretching, irregular stretching, and a family history of muscle cramping. In most cases, the cramp occurs as a result of repetitive exercise. When a muscle cramp occurs, the athlete will have extreme pain, the muscle will be involuntarily contracting, and the athlete will not be able to use the muscle group.

CausesAlthough the cause of EAMC has been researched for the past 50 years, there has yet to be one factor identified as the sole cause of the involuntary contraction. However, there are currently four theories that attempt to explain why this type of muscle cramping occurs: the serum electrolyte theory, the dehydration theory, the environmental theory, and the sustained alpha motor neuron theory. Although none of these theories fully explains the causes of EAMC, each has contributed to our knowledge and to the formulation of preventive and treatment options.

The serum electrolyte theory is based on observations that the involuntary muscle contractions are occurring in individuals who have a decreased concentration of electrolytes, such as sodium, potassium, magnesium, or calcium. Early research found differences in serum electrolyte concentrations between muscles that had cramped and those that had not.

However, the serum electrolyte imbalance would lead to general skeletal muscle cramping instead of muscle cramping in specific muscle groups involved in repetitive contractions, as is found with EAMC. In addition, recent studies of marathon runners found that there were no differences in serum electrolyte imbalances between pre-race, post-race, and post-recovery measurements. So, presently, there is insufficient evidence to fully support this theory of exercise-associated muscle cramping.

The dehydration theory is one of the most common ones used for explaining EAMC. This theory states that when an individual is dehydrated, the decrease in body mass, blood volume, and plasma volume leads to muscle cramping. Recent studies, however, have shown that there are no differences in body mass, blood volume, and plasma volume between subjects who suffered EAMC and those who did not. Therefore, there is very little objective data supporting this theory.

The environmental theory is based on the fact that when athletes are exposed to extreme environmental conditions, such as high heat and humidity, they are more susceptible to cramps. With this condition, athletes have lost a significant amount of fluid through sweat and thus have an electrolyte imbalance (as in the serum electrolyte and dehydration theories), which leads to muscle cramping. Evidence has shown, however, that the athletes’ core temperatures are not significantly higher when they are cramping compared to when they are not. Therefore, the environment cannot be said to cause an increase in muscle temperature, which is the postulated cause of the muscle cramp.

The most recent hypothesis for EAMC is offered by Drs. Schwellnus, Derman, and Noakes, from the University of Cape Town Medical School and the Bioenergetics of Exercise Research Unit of the Sports Science Institute of South Africa. They postulate that cramping occurs due to an abnormality of sustained alpha motor neuron activity, which continues the stimulus to the muscle to contract. As the muscle fatigues, an excitatory effect on the muscle spindle and an inhibitory effect on the golgi tendon organ affect the activity of the muscle, thus leading to the cramp. The mechanism of this hypothesis is not well understood and warrants further investigation.

PreventionAs mentioned, even though each of the above theories of muscle cramping are being challenged, they have all helped to devise techniques that have been used successfully in preventing recurrent EAMC. The most common of these include being properly conditioned, stretching regularly, and maintaining adequate nutrition and hydration.

Being properly conditioned is a key factor in preventing muscle cramps. When a muscle is not properly conditioned, it will have an earlier onset of fatigue. This may lead to the increased activity of alpha motor neuron activity and thus lead to cramping.

Athletes who have poor stretching habits are at greater risk for EAMC. When the muscle is not stretched sufficiently, an exaggerated myotonic reflex may occur, thus increasing the muscle spindle activity. The increased activity can lead to an increased fatigue rate and, ultimately, to a muscle cramp. Studies have shown that athletes with good stretching habits are less likely to have EAMC, thus supporting the alpha motor neuron theory.

Although proper conditioning and stretching are very important in minimizing the risk for muscle cramps, a proper diet and hydration have been the most strongly emphasized preventative techniques found in the literature. In order for an athlete to prevent muscle cramps, he or she should have a well-balanced diet that provides enough sodium, chloride, potassium, magnesium, and calcium. A balanced diet ensures that the athlete will take in enough nutrients so that he or she will not be deficient in any of the electrolytes needed to maintain normal muscle function. If the athlete is still cramping on a balanced diet, he or she should be encouraged to eat more potassium-rich foods and to lightly salt his or her food. Another approach that has been highly effective is to have the athlete ingest a small amount of pickle juice or mustard before each intense bout of exercise (generally, it is only necessary before game situations; see “The More Things Change,” below, and Sidebar, “A Shot A Day”).

TreatmentAlthough prevention is truly the best medicine for muscle cramps, the truth is that many athletes will not follow the above guidelines fully or may follow them, yet cramp up anyway. Once an athlete has begun to cramp, that individual will not be able to perform at his or her optimum until the cramp has been treated. Common treatments for acute EAMC are icing, stretching, massaging, and hydrating.

Ice is commonly used for decreasing muscle spasm and has been shown to be an effective modality in treating muscle cramps. The cramping muscle can be treated with a cold treatment placed directly on the area until the cramp has subsided. Although icing the area is an effective treatment, it usually needs to be combined with stretching.

Passively stretching the cramping muscle is an effective way to manage a muscle cramp. Once the cramp has begun, the muscle should be maintained in a stretched or lengthened position until the cramp ceases and the muscle returns to a normal relaxed state. While the muscle is being stretched, a constant grasp or massage of the muscle will usually help it to relax sooner. With a combination of ice, stretching, and massage, most muscle cramps go away in just a few minutes.

While the acute muscle cramp is being treated, the athlete should consume large amounts of water or sports drink to replenish the fluids lost during competition. Maintaining hydration will make the athlete less susceptible to a recurrence of cramping. However, once cramping has begun during exercise, most athletes cannot consume enough fluids to prevent further cramping. Newer trends in preventing and treating muscle cramps, though, have allowed athletes to return to competition without a recurrence of muscle cramping.

The More Things ChangeLike most folk remedies, it’s unclear how or when it was started, or by whom, but pickle juice has been used to prevent and treat cramps for decades, if not longer. It recently garnered increased attention when the Philadelphia Eagles used it—among other strategies—in their season-opener against Dallas. The Eagles won by a huge margin, unexpectedly, in extremely hot Dallas conditions. But attentive viewers of the pregame TV broadcast may have caught Terry Bradshaw say that, because they were forecasting temperatures as high as 140 degrees on the field that day, the players ought to be drinking pickle juice. Apparently, the Louisiana native regarded pickle juice as a staple in preparing for particularly hot games.

While no claims were made afterward about pickle juice as some sort of performance-enhancing drug, a flurry of media interest followed, citing it as a miracle cure for the effects of playing in the heat—namely, dehydration and cramping. A couple of months before that game, I had given a brief oral presentation at the NATA’s Annual Meeting in Nashville on my experience treating one athlete’s chronic cramps with pickle juice. Up to that point, I had treated about 100 athletes prophylactically with pickle juice—without a single failure—but this was one of the first athletes I had treated for acute cramps (see Sidebar, “A Shot A Day”).

I am by no means the only athletic trainer using pickle juice to prevent and treat muscle cramps. The Eagles athletic trainers reportedly heard about it from an athletic trainer at Iowa State and had been using it throughout most of their training camp. I first heard of the strategy about five years ago from a coach in El Paso, Texas. Apparently, in many parts of Texas (and, perhaps, neighboring Louisiana), they had been using it for years. It seems to be a well-known cure there, but no one seems to know where it first originated.

Exactly how it works remains a mystery as well. But the key ingredient seems to be the vinegar, because vinegar alone and mustard have yielded results similar to pickle juice.

Dr. Robert E. Agee of the Alabama Sports Medicine Institute treats acute exercise-associated muscle cramps with mustard. An athlete who begins to cramp is given one packet of mustard, washed down with water, every two minutes until the muscle cramp is gone. Although no formal research has been conducted to identify if, why, or how the mustard is working, Agee has had great results getting his athletes back into the game quickly.

Since the Philadelphia-Dallas game, I have received a flurry of calls from athletic trainers wondering how to use pickle juice. Apparently, other related parties, including pickle-maker Vlasic, have been flooded by calls as well. This has created an atmosphere where everyone from coaches to the athletes themselves have been tempted to try using pickle juice as part of their daily regimen—without a clue as to how to properly use it. The most important point to make is that an athlete cannot simply expect to prepare for a game, or thwart cramps, by downing a few gulps of pickle juice. How pickle juice is used, how it should be used, and the precautions one should take when using pickle juice are discussed in the Sidebar, “A Shot A Day”.Although science has yet to pinpoint the cause of muscle cramps, theory and experimentation have led to some reliable preventative measures. And whether you employ old standbys as treatments for acute cramps or newer methods, the emphasis should always be what is most effective—and safe—for the athlete.

Sidebar - A Shot A DayWe have been using pickle juice to prevent and treat muscle cramps at the University of Northern Iowa for the past three years. Primarily, the athletic training staff has used it as a last resort in treating or preventing exercise-associated muscle cramps. When all of the previously mentioned preventive techniques—proper conditioning, nutrition and hydration, and stretching—have been tried and have failed, we add pickle juice to the athlete’s pregame regimen. We have found that by giving two ounces of pickle juice to the athlete 10 minutes before exercise, even the most chronic cramper can remain cramp-free during high-intensity exercise.

Pickle juice also seems to effectively treat acute muscle cramps. We first found this out when an athlete who was on a pickle-juice regimen forgot to take his dose before a game. When he suffered severe bilateral cramps in his gastrocnemius, he was taken out of the game and given two ounces of pickle juice. The cramps were completely gone within 30 seconds. We have tried this technique with other athletes and found it to be universally effective, with the great majority of cramps not recurring.

Usually, two ounces of pickle juice will treat and prevent any cramp. There have been a few situations where the athlete was suffering from muscle cramps in more than one area, or the cramp was in a large muscle group, like the abdomen, and he or she was then given additional pickle juice. It is imperative that the athletic trainer advise the athlete to continue hydrating, keep a balanced diet, and to take pickle juice in moderation.

Additionally, we have treated muscle cramps by giving two ounces of straight vinegar to athletes who were experiencing an exercise-associated muscle cramp. It was found that the involuntary contraction went away in 15 to 30 seconds and did not recur. Although the straight vinegar has worked, it is very difficult for athletes to consume straight vinegar. Pickle juice is more palatable and has been accepted better by the athletes.

Vinegar is the obvious common ingredient in both mustard (which is used by some athletic trainers) and pickle juice. But, as yet, there is no experimental research that has explained the mechanism of how these treatments work.